Resident #7 arrived at Fairfield Nursing & Rehabilitation Center in February with stage IV cancer that had spread to the brain. The patient also had a severe pressure wound on the tailbone area measuring 3 by 2 centimeters that was classified as "unstageable with slough."
Within six days, the wound care team upgraded the classification to stage 4, the most severe type of pressure ulcer. Stage 4 wounds involve full thickness skin loss with extensive damage reaching muscle, bone or tendon.
The wound care specialists prescribed a specific treatment plan on February 19: Leptospermum honey applied once daily for 30 days, alginate calcium dressing once daily for 30 days, and gauze island dressing with border once daily for 30 days.
The wound care team repeated the same treatment orders during follow-up visits on February 26 and March 6.
But nursing staff never implemented the prescribed treatment.
Instead, they continued using a completely different approach. The facility's Treatment Administration Record shows nurses cleansed the wound with normal saline solution, then applied Mepilex dressing and covered it with gauze. This incorrect treatment was documented and signed off from February 13 through February 28, and again from March 1 through March 5.
The honey and alginate dressings ordered by wound care specialists were never used.
Federal inspectors discovered the treatment failure during a September complaint investigation. The Assistant Director of Nursing and RN unit manager both confirmed that nurses had failed to relay the wound care team's orders and enter them into the computer system.
Pressure ulcers develop when sustained pressure cuts off blood flow to tissue, causing cells to die. They typically form over bony areas like the tailbone, hips, and heels in patients who cannot reposition themselves regularly.
Stage 4 pressure ulcers represent the most serious form of these wounds. The damage extends through all skin layers into underlying muscle, bone, or supporting structures. Without proper treatment, they can lead to life-threatening infections.
The facility's failure affected treatment for weeks. While the wound care team made specific recommendations based on their clinical assessment, nursing staff continued using their original approach without implementing the prescribed changes.
Leptospermum honey, derived from the Manuka tree, has antimicrobial properties that can help prevent infection in severe wounds. Alginate calcium dressings are designed to absorb drainage while maintaining moisture levels that promote healing.
The Mepilex dressings used instead are foam dressings typically used for less severe wounds or different types of injuries.
For Resident #7, who was already battling advanced cancer with brain metastases, proper wound care was critical. Cancer patients face increased risks of infection and delayed healing due to compromised immune systems and the effects of treatment.
The inspection found that communication breakdowns between the wound care team and nursing staff left the patient without appropriate treatment for the serious pressure wound. The wound care specialists had evaluated the injury multiple times and prescribed specific treatments, but their orders never reached the nurses providing daily care.
Federal regulations require nursing homes to provide treatment and services to prevent new pressure ulcers and heal existing ones. The facility's failure to implement prescribed wound care violated these requirements.
The inspection classified the violation as causing "minimal harm or potential for actual harm." However, untreated stage 4 pressure ulcers can lead to serious complications including bone infections, blood poisoning, and in severe cases, death.
The facility acknowledged the communication failure during interviews with federal inspectors. Both the Assistant Director of Nursing and the RN unit manager confirmed that the wound care orders had not been properly relayed to nursing staff or entered into the treatment system.
This breakdown meant that despite having wound care specialists evaluate the patient and prescribe specific treatments, the daily nursing care continued unchanged for weeks.
Resident #7's case illustrates how administrative failures can directly impact patient care, even when appropriate medical expertise is available within the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fairfield Nursing & Rehabilitation Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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